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Needs and beliefs in construct accessibility: Keys to new understanding
Public Relations Review, 24(2): 125-143 ISSN: 0363-8111
Hugh M. Culbertson, CarlJ. Denbow, and Guido H. Stempel lII
Copyright © 1998 by JAI Press Inc. All rights of reproduction in any form reserved.
Needs and Beliefs in Construct Accessibility: Keys to New Understanding ABSTRACT: In a general-population survey of 390 Ohioans, respondents rated five concepts as to closeness of linkage with osteopathic medicine. As suggested by the storage-bin concept in construct-accessibility theory, those who had experience with these concepts were most apt to use them in assessing osteopathic medicine. This held even though most respondents reported no contact with osteopathy. Also, those satisfied with their health insurance tended more than others to weigh "niceties" such as wellness heavily in assessing osteopathy. At the other extreme, persons without health insurance gave strong emphasis to cost-containment when evaluating this health-care school. Dr. Hugh M. Culbertson is professor emeritus, and Dr. Guido H. Stempel III is distinguished professor emeritus, in the E. W. Scripps School of Journalism at Ohio University, Athens. Dr. Carl J. Denbow is director of communication in the Ohio University College of Osteopathic Medicine.
INTRODUCTION Attitude toward and credibility of clients and their projects appear to have moved somewhat offcenter stage recently in the scholarly Summer 1998
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literature of public relations. However, these concepts remain active in "supporting roles" as researchers seek to refme and test them. This study pursues such refinement by interpreting attitude and credibility in light of a theoretic perspective within cognitive psychology---construct accessibility. First, we discuss the role of attitude in the PR field briefly. More than 30 years ago, psychologist Leon Festinger found little evidence that attitude, as usually measured with paper-and-pencil tests, correlated with overt "payoff" behaviors of interest to applied communication scholars. 1 Later, sociologist Herbert Blumer 2 and communication scholar James Grunig 3 also criticized attitude research on philosophical grounds. These authors contended that such studies often failed to take into account the goal-oriented, situation-specific, socially constructed nature of human behavior. Recently, however, many studies have shown that attitude degree and direction do predict behavior quite well where respondents have freedom of behavioral choice. Kim and Hunter have reached that conclusion after reviewing available literature in a systematic meta-analysis.4 Another objection has stemmed from equating by some of persuasion and attitude change (or, sometimes, enhanced attitude stability) with public relations success. James Grunig and his colleagues have argued that the two-way symmetric model of public relations generally is most effective. 5 And that approach centers on relationship building, not persuasion. However, these authors (see especially L. Grunig, J. Grunig, and Ehling6) note that even idealistic clients must seek acceptance from--and avoid rejection by--key publics. Without acceptance, clients do not get resources needed to operate. Furthermore, J. Grunig, et al. report that successful organizations often uriliTe a "mixed-motive" approach combining two-way symmetric and persuasion-oriented two-way asymmetric public relations. 7 And Kathleen Kelly argues for fund raising strategies that avoid extreme emphasis on either autonomy (which implies an asymmetric tendency to impose organizational will and views on publics) or accountability (which entails almost complete subservience to publics) .8 In light of such analysis, two-way symmetric practice does not preclude concern with attitude change. A practitioner and client operating in this mode can--and must--seek such change as long as: • They take into account--and seek to meet--audience needs when setting goals. • They listen respectfully and with an open mind when communicating with publics, thus allowing for the possibility that they, too, may be persuaded. • They proceed in a flex/b/e way, changing communication goals as well as their own views in light of new information. 126
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LITERATURE REVIEW AND HYPOTHESES Research and theory have indicated that beliefs about and assessment of an attitude object become more stable--and perhaps more apt to influence one's thought processes and behavior--as linkages with varied other entities become stronger and more numerous. 9 Associationists have tended to view strength and number of linkages between attitude objects and goals or values as independent variables--as givens. Few have addressed very clearly what determines these linkages. However, in a series of studies, Culbertson and his colleagues have explored factors which appear to influence linkage beliefs about a university's alumni-relations department, 10 educational and service activities of a local police department, 11 a school of health care, 12 and a medical clinic. 13 Results suggest that people are apt to link an attitude object with a "linked object" where the two: have been experienced together frequently in time and space. are viewed as similar. are such that one appears to be part of the other. are related in an ego-involving way (i. e., acceptance or promotion of the linkage between them contributes to one's sense of worth and accomplishment). 5. are related in an instrumental way (i. e., associating oneself with the attitude object appears to enhance chances of achieving a desired goal such as a job--here treated as the linked object.)
1. 2. 3. 4.
Previous research has focused primarily on perceived relationships between attitude object and linked object where people have experienced the two in relation to each other or together. This study examines conditions under which people may "use" linked objects (here concepts often discussed within the health-care school called osteopathic medicine) in characterizing an attitude object (osteopathic physicians) even though knowledge of and apparent contact with the latter are and have been modest or non-existent. For example, doctors of osteopathy emphasize the importance of a close, caring relationship between physician and patient. Informing people about the need for such caring may help set the stage for eventual acceptance of osteopathy--even where, at the time of learning, those studied have never heard of that healthcare school. Education about concepts so people may then apply them in novel domains can have practical significance in public relations. Three implications stand out: . A stigmatizedgroup can profit, in the long run, from perceptions not initially linked to it. For example, osteopathic physicians were long regarded as quacks by the numerically dominant aUopathic (M. D.) school of health care in the United States. Also, D.O.s are Summer 1998
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confused on occasion with chiropractors, another somewhat stigmatized group. 14 As suggested in spiral-of-silence theory, disadvantaged groups are often reluctant to champion causes in public fora. 15 However, perhaps doctors of osteopathy (D.O.s) can at least gain a respectful hearing by linking their profession to widely accepted concepts such as emphasis on close doctorpatient relations.
. Competing professional, occupational, and political groups can work together in educating publics about key ideas or concepts if they recognize that each group will profit from enhanced overall understanding. Mutual understanding--a key goal in two-way symmetric public relations--may thereby be enhanced. In a related vein, Bellah, et al., 16 Palmer, 17 Kruckeberg and Starck, 18 and others have urged emphasis on such understanding--and a possible shared sense of purpose and community--in the modem world. .
Practitioners seeking to influence the diffusion of innovative belief and behavior systems such as osteopathic medicine will be encouraged to avoid what Everett Rogers refers to as the "empty vessels fallacy." According to this fallacy, prospective adopters approach new innovations with blank cognitive slates. 19 Change agents may assume that when they are innovationMrather than audience-oriented.
We now turn to the notion of construct accessibility. Construct
Accessibility
While not defined in the literature with complete uniformity, a construct is generally viewed as a variable or attribute which people use in defining something. Accessibility is seen as one's tendency to use a construct quickly, consistently, or in a way involving substantial time and effort. Recently, this variable has played a significant role in communication research. Tapper, 20 Shrum and O'Guirm, 21 and Shapiro22 have viewed it as a mediating factor which might help account for mass-media cultivation effects. Also, Pingree has referred to construct accessibility as an element in inference making, a process which can help explain young people's attention to television.23 In the literature, cited determinants of accessibility appear to fall within two basic categories: . Recency and frequency ofuse. Wyer and Srull,24 along with Tversky and Kahneman,25 emphasized recency of use in advancing their "storage-bin" model. These researchers postulate that a construct 128
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used recently goes to the top of the user's storage bin, making it easy to access when another pertinent object requires definition. On the other hand, George Kelly theorized that frequent use of a construct leads one to keep using it, consistently, over a long period.26 Bargh, et al. note that many studies fail to separate frequency and recency. These authors demonstrate that each of these factors can have impact with the other controlled. 27 They, along with Higgins, et al.28 have combined both in attempting to explain construct accessibility. . Motivation or need. Feather 29 suggested that, for example, an object's excitement value may become salient when he or she is bored in a given situation--and/or links liveliness and excitement to basic values of the type stressed by Rokeach. 3° Also, Hawkins, et al. found relatively high attention to a concept or idea when subjects viewed it as difficult to understand, yet probably soluble. sl These studies point to the importance of need in motivating people to use a construct. This focus on motivation is consistent with a good deal of work in various disciplines. Research suggests that, when one has an intense need, he or she places great emphasis on factors which might help meet that need. Once the need is actually or potentially met, however, a person may focus elsewhere. Theoretical bases include the following: 1. Abraham Maslow postulated that those lacking in food, clothing and shelter try hard to gain those things. Furthermore, once that's been accomplished, people work primarily to satisfy such "higher-order" needs as social approval and, ultimately, self-actualization. 32 2. Learning theorists Dewey and Humber note that, often, "The initial impetus to action comes from the innate drives, but once the behavior is set in motion..., there come into being ... socio~enic, secondary, learned or acquired drives, impulses, or needs. "3~ 3. In economics, the concept of diminishing marginal utility posits that, as a need is met, goods and services required to meet it lose value. For example, a hungry person may desire an initial cheeseburger for lunch with great intensity. But a third or fourth burger typically has little appeal. 34 Construct accessibility has been defined operationally in several ways. Included are actual use of the construct, as opposed to others, in making an assessment, 35 response latency or time required in estimation, 36 extremity of high or low values assigned, 37 number of instances or exemplars recalled,38 time Summer 1998
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spent attending to construct use, 39 and choice of behavior presumably based on construct assessment. 443 Research appears to shed little light on types o f construct use relating primarily to frequency and/or recency of use vs. need and motivation. We propose a beginning here based on two fundamental premises.
Premise 1. Simple placement of a construct at or near the top o f one's "storage bin" as a result of recent and/or frequent use may prime use of that construct in defining a relatively new object (in this study, osteopathic medicine). Such placement may not, in and of itself, trigger actual use of the accessed construct in assessing things such as the credibility of that new object. Price, et al., observe that some, but not all, accessed constructs are used in making subsequent evaluations. 41
Premise 2. Needs and motives may play an important role in such triggering. Where an especially salient need is not met, it should enhance use of a construct dearly related to that need (priming the construct as defined by Iyengar and Kinder42). But where the need has been met, other constructs may impact heavily on credibility assessment. Osteopathic Concepts Before deriving specific hypotheses, we pause to consider concepts central to osteopathic medicine. Open-ended interviews of osteopathic physicians and other health-care leaders in 1981-243 and 1991, 44 along with a thorough literature review, revealed seven inter-related concepts which serve as cornerstones of osteopathic philosophy and practice. Five were singled out for study here:
1. Treatment of the whole person. At least three meanings seem relevant. First, different organs and parts of the body are interdependent so that, for example, a liver ailment is apt to affect the heart, and vice versa. Second, mind, body and spirit are inter-related. And third, one's physical well-being hinges in large part on his or her psycho-social and physical environment. For example, an abusive home situation or constant exposure to cigarette smoke harms health. 2. Close, caring doctor-patient relations. These can improve patients' confidence and resolve--important factors in health care. 3. Wellness. Involved here are g o o d exercise, diet, and personal hygiene. A body which stays in good shape can often avoid iUnessmand fight it off when it comes. Much less money and pain are needed to avoid a heart attack than to cure or recover from it once it occurs. 130
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4. Osteopathic manipulative treatment. This set of treatment techniques involves using the hands to apply pressure and movement to the bones, joints, and muscles. 5. Family practice. A majority of D.O.s serve as "primary-care" physicians-family or general practitioners, general internists, and general pediatricians. Many feel general practitioners are needed more than ever to help patients manage their health care as a whole within an increasingly complex system of diagnosis, treatment and finance. Yet only a small fraction of allopathic physicians or M . D . s have opted for primary care in recent years. The survey also differentiated between those who had and had not engaged in three experiences presumed to create or enhance awareness of key concepts. Experiences were having a family physician, having heard of osteopathic manipulative treatment, and having discussed wellness with a physician in the past year. Analyses rested on the assumption that each of the three experiences noted involved at least some awareness of one of the concepts listed above. Those with a family physician seem apt to have some concern about caring doctor-patient relations--something often not available in clinics where a patient sees different physicians from visit to visit. Heating of OMT should insure that it enters one's "storage bin" used for future analysis of health-care practice and concepts. And likewise, discussion of wellness should place it in the bin. The three "experiences" differ greatly as to scope. Hearing of manipulative treatment involves decoding of at least--but perhaps only---one message as needed to gain awareness. The second experience, discussion of wellness, implies two-way, topic-specific doctor-patient interaction. And the third experience, having a family doctor, involves an ongoing relationship. In light of premise 1 above, such experiences should enhance accessibility of manipulative treatment, wellness, and doctor-patient relations in assessing osteopathic medicine--even by people who had little or no direct experience with osteopathy. This suggests: Hla: Those who have a family doctor link osteopathy to caring physicians more closely than do those without a family doctor. Hlb: Those who have heard of OMT link manipulation more closely to osteopathy than do those who have not heard of it. Hlc: Those who have discussed wellness with a physician in the past year link it more closely to osteopathy than do those who report no such discussions. Premise 2 suggests, however, that experiences involving exposure to the three constructs just noted may not influence use of those constructs in assessing osteopathic credibility. To test this, we examine three research questions, indexing such usage with product-moment correlations between closeness of linkage to osteopathy on the one hand and D.O. credibility on the other: Summer 1998
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RQla: Does the correlation between linkage of caring physicians to osteopathy and D.O. credibility differ between those who have a family physician and those who do not? RQlb: Does the correlation between linkage of manipulative treatment to osteopathy and D.O. credibility differ between those who have heard of manipulation and those who have not? RQlc: Does the correlation between linkage of wellness to osteopathy and D.O. credibility differ between those who have discussed wellness with physicians in the past year and those who have not? Hypotheses 2, 3a, 3b, and 3c focus on the extent to which presumed intensity ofpersonal need might "prime" one concept, cost, and make it salient in assessing osteopathy. Cost was chosen here because, in the survey, 78% of all respondents listed it, or a related concern for health-care availability, as "the most important problem facing American health care today." It's widely assumed that costs are an especially grave problem for those without what they regard as good health insurance. People worried about costs should also evaluate D.O. credibility partly on the basis of whether they link osteopathy to cost containment. Thus: H2: The correlation between linkage of osteopathy to cost containment and D.O. credibility is positive for the uninsured but not for those with health insurance. In formulating hypotheses 3a, 3b, and 3c, we focused on three concepts for which linkage to osteopathy correlated positively and significantly with D.O. credibility for the sample taken as a whole. These constructs were wellness, caring physicians, and treatment of the whole person. We presume that respondents very satisfied with their health insurance regard cost-related needs largely as met for themselves. That fact, along with premise 2 above, suggest: H3a: Linkage of wellness to osteopathy correlates positively with D.O. credibility among those very satisfied with their health insurance, but not among the less satisfied. H3b: Linkage of whole-person treatment to osteopathy correlates positively with D.O. credibility among the very satisfied insurance customers, but not among the less satisfied. H3c: Linkage of caring physicians to osteopathy correlates positively with D.O. credibility among the very satisfied insurance customers, but not among the less satisfied. Premises 1 and 2 above provide little reason to believe motivation, in and of itself, enhances construct use in simply defining an object. To provide some cues on this, we explore three research questions: 132
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Needs and Beliefiin ConstructAccessibility RQ2a: Does closeness of linkage between wellness and osteopathy differ between those very satisfied with their health insurance and those who are less satisfied or are uninsured? RQ2b: Does closeness of linkage between whole-person treatment and osteopathy differ between those very satisfied with their health insurance and those who are less satisfied or are uninsured? RQ2c: Does closeness of linkage between caring physicians and osteopathy differ between those very satisfied with their health insurance and those who are less satisfied or are uninsured?
METHODOLOGY
Sampling Data were collected by phone, and random digit dialing was used to select a sample o f Ohioans. Numbers identified by recordings as nonworking were not counted in computing the response rate of about 60%, which was nearly identical for the state's extant area codes. Where no response or recording was encountered, interviewers made three caU-backs at least 24 hours apart before coding a given number as a non-response. In all, 390 interviews were completed. Interviewing Students in journalism and political communication at the researchers' university served as interviewers. Most were graduate students. All underwent intensive training and practice for about two hours before collecting data. The researchers supervised interviewing constantly during data collection, which took about three weeks in late April and early May 1991. Interviews lasted for about 15 minutes.
Measurement Several questions were repeated from a survey completed about nine years earlier by two of the authors to permit analysis of change over time. Such analyses are summarized elsewhere.45 Approximately 20 pre-test interviews were completed, and mid-course corrections in question wording made, prior to actual data collection. Linkage beliefi. Respondents were given the following question: Now I am going to read off a few concepts relating to health care. Please tell me how closely you believe each concept is linked to osteopathic medicine today. Is the connection with osteopathy very close? Fairly close? Or not close at all? Summer1998
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Concepts rated were manipulative treatment, wellness (diet, exercise, and lifestyle measures), treatment of the whole person, lowering of health-care costs, and caring physicians. Linkage ratings were obtained near the end of the questionnaire. Questions about the Linkage constructs had been asked earlier but were interspersed with other items to avoid priming specific linkages. Further, prior questions were worded so as to suggest an association between only one linking construct, manipulation, and osteopathy. These questions came early in the questionnaire. And, it would seem, any priming effect of prior questions should have held about equally across subjects. Having or not having learning experiences. Questions used to measure these three dichotomous variables were as follows: Do you have a family physician to whom you go regularly? Have you ever heard the term "manipulative treatment"? These days, quite a few Americans are trying to stay well through exercise, diet, avoidance of drinking or smoking, and other so-called wellness efforts. Do you recall discussing wellness practices or concerns with a physician during, say, the past year, or not?
D.O. credibility. Respondents indicated their levels of agreement or disagreement with the statement that "Osteopathic physicians are at least as well qualified and trained, on the whole, as medical doctors or M.D.s." Options given were agree strongly, agree somewhat, disagree somewhat, and disagree strongly. Health-insurance posture. Respondents first indicated whether they had health insurance, offered by a private firm, to help pay for hospitalization, drugs, and other health care. Then those with insurance were asked whether they were very satisfied with it, fairly satisfied, or not satisfied at all. Only 10% of those answering said they were not satisfied at all, so the SPSS-PC+ RECODE command was used to combine the "not satisfied at all" and "fairly satisfied" categories in analysis.
Analysis Means were analyzed with multiple classification analyses, using education level as a covariate likely to correlate with active linkage and credibility assessment. MCA provides F ratios as tests of significance and standardized beta weights akin to those in multiple regression, indicating the predictive power of variables measured on a nominal scale. In testing other hypotheses, product-moment correlations were computed between D.O. credibility and the closeness of linkage between osteopathy and specific healS-care concepts. Predictions were directional in every case, so onetail tests of significance were used. Where appropriate, correlation coefficients were converted to the Fisher Z statistic and differences between them were tested for significance. ~ 134
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Inspection of mean scores confirmed that relationships were close to being linear as assumed with product-moment correlation. Interaction tests with analysis of variance confirmed that no two correlations which were compared differed primarily because one defined a linear relationship and the other did not. Uninsured respondents, those who were not fairly or not at all satisfied with their health insurance, and the very satisfied insurees might differ as to education and age--factors which could affect health-care assessment. However, observed differences were slight and did not approach statistical significance.
RESULTS
Sample Description The sample proved quite representative of all Ohioans as demographics, based on the 1990 U. S. Census. Median age was 37.5 years for sample members, compared with 33.3 years for the population as a whole.47 (A difference of roughly this magnitude was expected because no one under age 18 was interviewed.) Women and highly educated people were over-represented somewhat as often occurs in survey research. 48 With respect to the learning experiences noted above, 80% of the respondents reported having regular family doctors. Also, about 31% said they had heard of osteopathic manipulative treatment. Of these, few appeared to have drastic misconceptions about these procedures. Finally, 51% of the respondents reported discussing wellness with a physician during the past year. Moving to linkage beliefs, only 15% of all respondents who assessed doseness of linkage saw a very dose tie between osteopathy and lowering of costs, while 36% said the connection was "not close at all." "Very close" ratings were in the range of 36% to 45% for the other four concepts (OMT, wellness, treatment of the whole person, and caring physicians). And between 47% and 55% saw fairly close ties between osteopathy and each of the five variables. In another area, 14% of all respondents said they did not have health insurance. Of those who were insured, 39% reported being very satisfied with their coverage, while 51% were fairly satisfied and 10% were not satisfied at all. In assessing D.O. credibility, 37% of all respondents indicated they could not assess the validity of the statement that D.O.s are at least as well trained and qualified as M.D.s. Of the remainder, 26% disagreed with the statement, 46% agreed somewhat, and 28% agreed strongly. to
Hypothesis Tests Hypothesis la asserts that those with family physicians link osteopathy more closely to "caring physicians" than do those without family doctors. Table 1 provides confirmation here, though with a fairly weak associaSummer 1998
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tion (b=.17) with education and the other two "learning experiences" controlled. Hypothesis lb specifies that those who have heard of OMT link it to osteopathy more closely than those who report no awareness of manipulation. This difference is moderate (b--.30) and highly significant. Hypothesis lc posits that those who have discussed wellness with physicians in the past year link it more closely with osteopathy than do others. While the difference between means in table 1 is in the predicted direction, it approaches but does not attain significance (p=.088). In sum, those who have family doctors--and those who have learned of OMT--link osteopathy more closely to concepts associated clearly with these experiences than do others. A similar difference involving wellness was in the predicted direction but not significant. While modest, the differences observed seem noteworthy because they appear to hold despite limited contact with osteopathy. Less than 5% of the total sample reported having D.O.s as family physicians. Also, the reported relationships held, with minimal change and without exception, where this group of 19 was excluded from the analysis. Previous research also suggests low awareness by the general public of this school of medical practice. In one study, some people who had been diagnosed or treated at an osteopathic hospital did not realize they had done so, suggesting low general awareness of osteopathy even among some of its customers.49 And research has also shown low media coverage of osteopathy--as well as low awareness of it among those lacking personal contact with D.O.s and osteopathic hospitals, s0 Research questions la, lb, and lc ask whether the correlation between linkage of three concepts to osteopathy and D.O. credibility differs between those who've had learning experiences which might "prime" the concepts and those who have not. In relation to research question la, the correlation between linkage of osteopathy to caring doctors and D.O. credibility was positive (r--.23, p <.01) for those who had family physicians. However, the correlation became non-significant (r= .17) for those who did not have family doctors (see Table 2). Turning to research question lb, the correlation between linkage of manipulation to osteopathy and D.O. credibility was positive for those aware of OMT (r=.18, p <.05), but negative among the "non-hearers" (r=-.20, p <.01). Furthermore, the difference between these two correlations was significant (t=2.56, p <.01, one-tail test). These results suggest an interesting interpretation. Some who'd not heard of OMT apparently said, in effect, "We don't know what it is, but we don't like the sound of it. Therefore, we view osteopathy as a bit suspect to the extent that it deals with manipulation." Of course, the results may stem from negative connotations for the word manipulate. Research question lc focused on the correlation between linkage of wellness to osteopathy and D.O. credibility. Consistent with a priming effect, the 136
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Needs and Beli~ in Comtruct Accessibility TABLE
1
Mean Linkage Scores on Manipulation, Wellness, and Caring Physicians for Those with and without Related Learning Experiences Those with Experience
Those without Experience
p
b+
Reported Awareness
2.51 (n--96)
2.08 (n--120)
.001
.30
Wellness
Discuss with Physician
2.41 ( n = 1 2 8 )
2.29 ( n = 1 0 5 )
.088
.12
Caring Physician
H a v e Family Doctor
2.34 ( n = 1 7 1 )
2.00 ( n = 3 4 )
.005
.17
Concept
Experience
Manipulation
Note: +Standardized beta weights were generated in multiple classificationanalysis, with F-tests used to determine significance levels.Means were adjusted for education levelas a covariatein computing F values and beta weights.
correlation was positive and significant only among those who'd discussed wellness with physicians during the past year (r=.26, p <.01). No significant association was found (r--.15, p >.05) among the non-discussants. Overall, then, those with experiences apt to enhance awareness of key concepts (OMT, caring physicians, and wellness) showed demonstrable positive correlations between closeness of linkage and D.O. credibility. Those who lacked such experiences did not. Conceivably, negative reactions to the word "manipulation" by people unaware of this treatment mode might have influenced responses to the concepts of wellness and caring physicians. To check this, partial correlations were computed for correlations between D.O. credibility on the one hand and wellness or caring physicians on the other, controlling for awareness of manipulation. Partialing changed none of the correlations in Table 2 by more than .01, suggesting little if any such halo effect. A caveat is in order, however. Only with osteopathic manipulative therapy were the correlations between the "experiencers" and the "non-experiencers" significantly different. Furthermore, in the case of caring physicians, the small number of people without family physicians (only 20% of the sample) reduced the power of this statistical test greatly. Thus confirmation that the three learning experiences "primed" related concepts in assessing osteopathic credibility must be viewed as highly tentative. As noted earlier, people with pertinent experiences apparently linked caring physicians, OMT, and wellness to osteopathy--and tended to use it as a basis for assessing D.O. credibility--even though they'd had little or no experience with osteopathic medicine. To further check this interpretation, we calculated the correlations used to test hypothesis 2 while excluding the 19 people (4.8% of the sample) who reported having D.O.s as family physicians from the analysis. No correlation changed significantly. Summer 1998
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TABLE 2 Product-moment Correlations between Linkage to Osteopathy and D.O. Credibility among Those with and without Relevant Learning Experiences Those with Experience
Concept
Experience
Manipulation
Awareness
.18" (n=88)
Wellness
Discuss with Physician
Caring Physician
H a v e Family Doctor
Those without Experience
t
pa
-.20* (n=90)
2.56
.01
.26** (n= 104)
.15 (n = 84)
0.78
nsd
.23** ( n = 139)
.17 (n = 26)
0.29
nsd
Notes: *p < .05, 1-tailtest; **p < .01, 1-tail test. aProbability basedon t-test of differencesbetween correlationsconvertedto Fisher Z statistic.
Hypothesis 2 specifies a positive correlation between linkage of osteopathy to cost containment and D.O. credibility among those without health insurance, but not among the insured. As expected, r=.35 (n= 16, p=.09, onetail) for the uninsured, but only -.07 (nsd) for those who had insurance. The difference between these two correlations approached, but did not attain, significance (t=1.58, p=.06, one-tail). Thus there was only tentative confirmation of hypothesis 2. While substantial, the difference between these correlations was not significant in light of the small number of uninsured respondents. As stated in hypothesis 3a, linkage ofweUness to osteopathy correlated significantly with D.O. credibility among the very satisfied insurance customers (r=.28, p <.05, one-tail), but not among the less satisfied people (r=.12, nsd). However, the difference between these two correlations did not approach significance (t= 1.02, nsd) (see Table 3). AS expected with hypothesis 3b, linkage of whole-person treatment with D.O. credibility correlated significantly among the very satisfied insurance customers (r=.43, p <.01), but not among the less satisfied (r=.10, nsd). Furthermore, the difference between these two correlations was significant (t=2.09, p <.025, one-tail). AS predicted in hypothesis 3c, there was a significant positive correlation between linkage of whole-person treatment and D.O. credibility among the very satisfied insurance customers (r=.39, p <.01), but not among the less satisfied (r=.10, nsd). Furthermore, the difference between these two correlations was significant (t= 1.76, p <.05, one-tail). In sum, then, data on hypothesis 2 suggest tentatively that concern for cost among the uninsured may "prime" that concept as defined by Iyengar and Kinder (1993, pp. 63-72). At least some of the uninsured appeared to rely quite heavily on cost concerns when assessing osteopathy. 138
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Needs and Beliefi in Censtr~t Accessibility TABLE 3
Product-moment Correlations between Linkage to Osteopathy and D.O. Credility among Very Satisfied and Less Satisfied Health-Insurance Customers Concept
Very S a t i ~ d with Health Insurance
Not Very Satirfied or Not Satisfi~d A t All
ta
p
Wellness
.28"* (n--70)
.12 (n--96)
1.02
nsd
Whole-Person Treatment
.43"* (n= 68)
.10 (n= 97)
2.09
.02
Caring Physician
.39** (n=64)
.10 (n=88)
1.76
.05
Notes:
**p < .01, 1-tail. aProbability based on t-test of differences between correlations converted to Fisher Z statistic.
Also the data on hypotheses 3a, 3b, and 3c suggest lack of such priming-with cost receding into the background--among the very satisfied insurance customers. These people, in turn, appear to assess osteopathy partly on the basis of its perceived connection with such health-care "luxuries" as wellness, caring physicians, and whole-person treatment. Research questions 2a, 2b, and 2c asked whether those very satisfied with their health insurance, the less satisfied insurees, and the uninsured differed as to closeness of linkage between wellness, whole-person treatment, and caring physicians, respectively, with osteopathy. Table 4 reveals a negative answer in each case, with no difference approaching statistical significance. Apparently, then, those satisfied with health insurance did not "downplay" cost concerns in a way which led them to link other concepts closely to osteopathic medicine. TABLE 4
Mean Linkage Scores on Wellness, Caring Physicians and Whole-Person Care for Those without Health Insurance and Insured Persons with Varied Levels o f Satisfaction Not Very,
Fairty
Very
Uninsured
Satisfied
Satisfied
F
df
p
Wellness
2.31
2.28
2.40
1.06
2/235
.35
Whole-Person Care
2.41
2.28
2.44
1.71
2/237
.18
Caring Physician
2.22
2.25
2.31
0.27
2/208
.76
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SUMMARY AND CONCLUSIONS Data were collected by telephone from a general-population sample of 390 Ohioans. Respondents rated five concepts as to closeness of linkage with osteopathic medicine. Concepts were treatment of the whole person, dose doctor-patient relations, wellness, osteopathic manipulative treatment, and family medical practice. In general, data supported the following conclusions: 1. Despite limited prior contact with osteopathic medicine, respondents linked the concepts quite closely to this health-care field. In cognitive-theory terms, they pulled concepts out of their "mental storage bins" when defining osteopathy. 2. Those reporting experiences likely to enhance recency and frequency of construct use linked constructs more closely to osteopathy than did people lacking such experience. 3. Those without health insurance--along with those who expressed at least some dissatisfaction with their insurance--had a substantial positive correlation between linkage of cost to osteopathy and osteopathic credibility, though the relationship narrowly failed to reach conventional significance levels in light of a small number of cases. This correlation disappeared among the highly satisfied insurees. The data suggest tentatively that concern with cost went with a fek need which "primed" that factor somewhat in assessing D.O. credibility. 4. In general, those very satisfied with their health insurance showed relatively high correlations between linkage of other selected concepts (doctorpatient relations, whole-person treatment, and wellness) to osteopathy and D.O. credibility. Among these respondents, "de-priming" of cost may have opened the way for assigning weight to other constructs. In sum, recency and frequency of concept use appeared to enhance accessibility so as to encourage linking of constructs with osteopathic medicine. Presumed respondent need did not correlate with closeness of linkage. However, need was associated with the further step of using constructs in evaluating credibility of the associated school of osteopathic medicine. Construct accessibility qualifies as a fruitful area for public relations research. It suggests ways in which educational activity can lay a "cognitive groundwork" for assessment of a new or relatively unknown program, institution, or profession. Further, it supports the potential utility of cooperative public relations and educational activity among disparate, or even competing, professions. Such cooperation seems needed in light of recent calls for enhanced emphasis on mutual understanding and a sense of community. A c k n o w l e d g m e n t : This article is a revised version of a paper originally presented to the Public Relations Division, Association for Education in Journalism and Mass Communication, during the AEJMC annual conference in Kansas City, MO, August 11-14, 1993. 140
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NOTES 1. Leon Festinger, "Behavioral Support for Opinion Change," Public Opinion Quarterly 28 (1964), pp. 404-417. 2. Herbert Blumer, Symbolic Interactionism: Perspectiveand Method (Englewood Cliffs, NJ: Prentice-Hall, 1969), pp. 93-100. 3. James E. Grunig, "Communication Behaviors and Attitudes of Environmental Publics: Two Studies,"Journalism Monographs 81 (1983), pp. 4-9. 4. Min-Sun Kim and John E. Hunter, "Attitude-Behavior Relations: A Meta-Analysis of Attitudinal Relevance and Topic," Journal of Communication 43 (1993), pp. 101142. 5. James E. Grunig, ed. Excellence in Public Relations and Communication Management (Hillsdale, NJ: Lawrence Erlbaum Associates, 1992). 6. Larissa A. Grunig, James E. Grunig, and William P. Ehling, "What is an Effective Organization?" in James E. Grunig (ed.), Excellence in Public Relations and Communication Management (Hillsdale, NJ: Lawrence Erlbaum Associates, 1992), pp. 6590. 7. James E. Grunig, Larissa A. Grunig, and Dejan Vercic, "The Status of Public Relations in Slovenia: Extending the IABC's Excellence Project," paper presented to the Association for the Advancement of Policy, Research, and Development in the Third World, Cancun, Mexico, November 1996. 8. Kathleen S. Kelly, '~Fhe Fund-Raising Behavior of U. S. Charitable Organizations: An Explanatory Study," Journal of Public Relations Research 7 (1995), pp. 111-137. 9. Norman H. Anderson, "Cognitive Algebra: Integration Theory Applied to Social Attribution," in Leonard Berkowitz (ed.), Cognitive Theories in Social Psychology (New York: Academic Press, 1978), pp. 1-101; Martin Fishbein and Icek Ajzen, "Acceptance, Yielding and Impact: Cognitive Processes in Persuasion," in Richard E. Petty, Thomas M. Osttom, and Timothy C. Brock (eds.), Cognitive Responses in Persuasion (Hillsdale, NJ: Lawrence Erlbaum Associates, 1981), pp. 339-359; Milton J. Rosenberg, "A Structural Theory of Attitude Dynamics," Public Opinion Quarterly 14 (1960), pp. 319-340; Joseph Woelfel, Michael J. Cody, James Gillham, and Richard A. Holmes, "Basic Premises of Multidimensional Attitude Change Theory: An Experimental Analysis," Human Communication Research 6 (1980), pp. 153-167. 10. Hugh M. Culbertson, "Linkage Beliefs: What are the Links?" Public Relations Review 18 (1992), pp. 335-347. 11. Hugh M. Culbertson and Hochang Shin, "Police in America: A Study of Changing Institutional Roles as Viewed by Constituents," in James E. Gnanig and Larissa A. Grunig (eds.), Public Relations ResearchAnnual 1 (1989), pp. 155-174. 12. Hugh M. Culbertson and Guido H. Stempel III, "Linkage Beliefs and Public Relations Effects," Public Relations Research and Education 2 (1985), pp. 23-35. 13. Carl J. Denbow and Hugh M. Culbertson, "Linkage Beliefs and Diagnosing an Image," Public Relations Review 11 (1985), pp. 29-37. 14. Hugh M. Culbertson and Guido H. Stempel III, A Study of the Public Relations Posture of Osteopathic Medicine in Ohio (Columbus, OH: Ohio Osteopathic Association, 1982), pp. 46-47. 15. D. Garth Taylor, "Pluralistic Ignorance and the Spiral of Silence: A Formal Analysis," Public Opinion Quarterly 46 (1982), pp. 311-335. Summer1998
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16. Robert N. BeUah, Richard Madsen, William M. Sullivan, Ann Swidler, and Steven M. Tipton, The Good Society (New York: Vintage Books, 1992), pp. 179-219. 17. Parker J. Palmer, The Company of Strangers: Christians and the Renewal of America's Public Life (New York: Crossroad, 1992), pp. 17-33. 18. Dean Kruckeberg and Kenneth Starck, Public Relations and Community: A Reconstructed Theory (New York: Praeger, 1988), pp. 111-119. 19. Everett M. Rogers, Diffusion of Innovations (New York: Free Press, 1995), pp. 240242. 20. John Tapper, "The Ecology of Cultivation: A Conceptual Model for Cultivation Research," Communication Theory 5 (1995), pp. 36-57. 21. L.J. Shrum and Thomas C. O'Guinn, "Processes and Effects in the Construction of Social Reality: Construct Accessibility as an Exploratory Variable," Communication Research 20 (1993), pp. 436--471. 22. Michael A. Shapiro, "Memory and Decision Processes in the Construction of Social Reality," Communication Research 18 (1991), pp. 3-24. 23. Suzanne Pingree, "Children's Cognitive Processes in Constructing Social Reality," ]ournalismQuarterly 60 (1983), pp. 415422. 24. Robert S. Wyer and Thomas K. Snail, "Category Accessibility: Some Theoretical and Empirical Issues Concerning the Processing of Social Stimulus Information," in E. Tory Higgins, C. Peter Herman, and Mark P. Zanna (eds.), Social Cognition: The Ontario Symposium, Vol. 1 (Hillsdale, NJ: Lawrence Erlbaum Associates, 1981), pp. 161-197. 25. Amos Tversky and Daniel Kahneman, "Availability: A Heuristic for Judging Frequency and Probability," Cognitive Psychology 5 (1973), pp. 207-232; Amos Tversky and Daniel Kahneman, "Judgment Under Uncertainty: Heuristics and Biases," Science 85 (1974), pp. 1124-1131. 26. George A. Kelly, The Psychology of Personal Constructs (New York: W. W. Norton, 1955), pp. 72-77. 27. John A. Bargh, Ronald N. Bond, Wendy J. Lombardi, and Mary E. Tota, "The Additive Nature of Chronic and Temporary Sources of Construct Accessibility," Journal of Personality and SocialPsychology 50 (1986), pp. 869-878. 28. E. Tory Higgins, Nicholas A. Kuiper, and James M. Olson, "Social Cognition: A Need to Get Personal," in E. Tory Higgins, C. Peter Herman, and Mark P. Zanna (eds.), Social Cognition: The Ontario Symposium, Vol. 1 (Hillsdale, NJ: Lawrence Erlbaum Associates, 1981), pp. 395420. 29. Norman T. Feather, "Bridging the Gap between Values and Actions," in E. Tory Higgins and Richard M. Sorrentino (eds.), Handbook of Motivation and Cognition: Foundations of Social Behavior, Vol. 2 (New York: Guilford Press, 1990), pp. 151192. 30. Milton Rokeach, BelieJk,Attitudes and Values (San Francisco: Jossey-Bass, 1968). 31. Robert P. Hawkins, Yong-Ho Kim, and Suzanne Pingree, "The Ups and Downs of Attention to Television," Communication Research 18 (1991), pp. 53-76. 32. Abraham H. Maslow, "Psychological Data and Value Theory," in Abraham H. Maslow (ed.), New Knowledge in Human Values (Chicago: Henry Regnery Co., 1959), pp. 123-135. 33. Richard Dewey and Wilbur J. Humber, The Development of Human Behavior (New York: Macmillan, 1951), p. 171. 34. D.W. Moffat, EconomicsDictionary (New York: Elsvier, 1976), p. 178. 35. Tversky and Kahneman, 1973, op. cit.; Tversky and Kahneman, 1974, op. cit. 142
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45. 46. 47. 48. 49. 50.
Shnam and O'Guinn, op. cit. Bargh, et al., op. cit. Shapiro, op. cit. Pingree, op. cit. Feather, op. cit. Vincent Price, David Tewksbury, and Elizabeth Powers, "Switching Trains of Thought: The Impact of News Frames on Readers' Cognitive Responses," Communication Research 24 (1997), pp. 481-506. Shanto Iyengar and Donald R. Kinder, News That Matters: Television and American Opinion (Chicago: University of Chicago Press, 1987), pp. 63-72. Culbertson and Stempel, 1982, op. cit. Hugh M. Culbertson, Carl J. Denbow, and Guido H. Stempel III, "David and Goliath Co-Exist: The Story of Osteopathic Public Relations," in Hugh M. Culbertson, Dennis W. Jeffers, Donna B. Stone, and Martin Terrell (eds.), The Social, Political and Economic Contexts in Public Relations: Theory and Cases (Hillsdale, NJ: Lawrence Erlbaum Associates, 1993), pp. 227-269. Ibid. Quinn McNemar, Psychological Statistics (New York: John Wiley and Sons, 1963), p. 140. 1990 Census of Population: General Population Characteristics, Ohio (Washington, DC: U. S. Department of Commerce, 1990), p. 1. 1990 Census of Population and Housing: Summary Social, Economic, and Housing Characteristics, Ohio (Washington, DC: U. S. Department of Commerce, 1990), p. 59; 1990 Census of Population: General Population Characteristics, op. cir., p. 127. Culbertson and Stempel, 1982, op. cit., p. 43. Culbertson, Denbow, and Stempel, 1993, op. cit., pp. 253-255.
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Hugh M. Culbertson, CarlJ. Denbow, and Guido H. Stempel lII
Copyright © 1998 by JAI Press Inc. All rights of reproduction in any form reserved.
Needs and Beliefs in Construct Accessibility: Keys to New Understanding ABSTRACT: In a general-population survey of 390 Ohioans, respondents rated five concepts as to closeness of linkage with osteopathic medicine. As suggested by the storage-bin concept in construct-accessibility theory, those who had experience with these concepts were most apt to use them in assessing osteopathic medicine. This held even though most respondents reported no contact with osteopathy. Also, those satisfied with their health insurance tended more than others to weigh "niceties" such as wellness heavily in assessing osteopathy. At the other extreme, persons without health insurance gave strong emphasis to cost-containment when evaluating this health-care school. Dr. Hugh M. Culbertson is professor emeritus, and Dr. Guido H. Stempel III is distinguished professor emeritus, in the E. W. Scripps School of Journalism at Ohio University, Athens. Dr. Carl J. Denbow is director of communication in the Ohio University College of Osteopathic Medicine.
INTRODUCTION Attitude toward and credibility of clients and their projects appear to have moved somewhat offcenter stage recently in the scholarly Summer 1998
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literature of public relations. However, these concepts remain active in "supporting roles" as researchers seek to refme and test them. This study pursues such refinement by interpreting attitude and credibility in light of a theoretic perspective within cognitive psychology---construct accessibility. First, we discuss the role of attitude in the PR field briefly. More than 30 years ago, psychologist Leon Festinger found little evidence that attitude, as usually measured with paper-and-pencil tests, correlated with overt "payoff" behaviors of interest to applied communication scholars. 1 Later, sociologist Herbert Blumer 2 and communication scholar James Grunig 3 also criticized attitude research on philosophical grounds. These authors contended that such studies often failed to take into account the goal-oriented, situation-specific, socially constructed nature of human behavior. Recently, however, many studies have shown that attitude degree and direction do predict behavior quite well where respondents have freedom of behavioral choice. Kim and Hunter have reached that conclusion after reviewing available literature in a systematic meta-analysis.4 Another objection has stemmed from equating by some of persuasion and attitude change (or, sometimes, enhanced attitude stability) with public relations success. James Grunig and his colleagues have argued that the two-way symmetric model of public relations generally is most effective. 5 And that approach centers on relationship building, not persuasion. However, these authors (see especially L. Grunig, J. Grunig, and Ehling6) note that even idealistic clients must seek acceptance from--and avoid rejection by--key publics. Without acceptance, clients do not get resources needed to operate. Furthermore, J. Grunig, et al. report that successful organizations often uriliTe a "mixed-motive" approach combining two-way symmetric and persuasion-oriented two-way asymmetric public relations. 7 And Kathleen Kelly argues for fund raising strategies that avoid extreme emphasis on either autonomy (which implies an asymmetric tendency to impose organizational will and views on publics) or accountability (which entails almost complete subservience to publics) .8 In light of such analysis, two-way symmetric practice does not preclude concern with attitude change. A practitioner and client operating in this mode can--and must--seek such change as long as: • They take into account--and seek to meet--audience needs when setting goals. • They listen respectfully and with an open mind when communicating with publics, thus allowing for the possibility that they, too, may be persuaded. • They proceed in a flex/b/e way, changing communication goals as well as their own views in light of new information. 126
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LITERATURE REVIEW AND HYPOTHESES Research and theory have indicated that beliefs about and assessment of an attitude object become more stable--and perhaps more apt to influence one's thought processes and behavior--as linkages with varied other entities become stronger and more numerous. 9 Associationists have tended to view strength and number of linkages between attitude objects and goals or values as independent variables--as givens. Few have addressed very clearly what determines these linkages. However, in a series of studies, Culbertson and his colleagues have explored factors which appear to influence linkage beliefs about a university's alumni-relations department, 10 educational and service activities of a local police department, 11 a school of health care, 12 and a medical clinic. 13 Results suggest that people are apt to link an attitude object with a "linked object" where the two: have been experienced together frequently in time and space. are viewed as similar. are such that one appears to be part of the other. are related in an ego-involving way (i. e., acceptance or promotion of the linkage between them contributes to one's sense of worth and accomplishment). 5. are related in an instrumental way (i. e., associating oneself with the attitude object appears to enhance chances of achieving a desired goal such as a job--here treated as the linked object.)
1. 2. 3. 4.
Previous research has focused primarily on perceived relationships between attitude object and linked object where people have experienced the two in relation to each other or together. This study examines conditions under which people may "use" linked objects (here concepts often discussed within the health-care school called osteopathic medicine) in characterizing an attitude object (osteopathic physicians) even though knowledge of and apparent contact with the latter are and have been modest or non-existent. For example, doctors of osteopathy emphasize the importance of a close, caring relationship between physician and patient. Informing people about the need for such caring may help set the stage for eventual acceptance of osteopathy--even where, at the time of learning, those studied have never heard of that healthcare school. Education about concepts so people may then apply them in novel domains can have practical significance in public relations. Three implications stand out: . A stigmatizedgroup can profit, in the long run, from perceptions not initially linked to it. For example, osteopathic physicians were long regarded as quacks by the numerically dominant aUopathic (M. D.) school of health care in the United States. Also, D.O.s are Summer 1998
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confused on occasion with chiropractors, another somewhat stigmatized group. 14 As suggested in spiral-of-silence theory, disadvantaged groups are often reluctant to champion causes in public fora. 15 However, perhaps doctors of osteopathy (D.O.s) can at least gain a respectful hearing by linking their profession to widely accepted concepts such as emphasis on close doctorpatient relations.
. Competing professional, occupational, and political groups can work together in educating publics about key ideas or concepts if they recognize that each group will profit from enhanced overall understanding. Mutual understanding--a key goal in two-way symmetric public relations--may thereby be enhanced. In a related vein, Bellah, et al., 16 Palmer, 17 Kruckeberg and Starck, 18 and others have urged emphasis on such understanding--and a possible shared sense of purpose and community--in the modem world. .
Practitioners seeking to influence the diffusion of innovative belief and behavior systems such as osteopathic medicine will be encouraged to avoid what Everett Rogers refers to as the "empty vessels fallacy." According to this fallacy, prospective adopters approach new innovations with blank cognitive slates. 19 Change agents may assume that when they are innovationMrather than audience-oriented.
We now turn to the notion of construct accessibility. Construct
Accessibility
While not defined in the literature with complete uniformity, a construct is generally viewed as a variable or attribute which people use in defining something. Accessibility is seen as one's tendency to use a construct quickly, consistently, or in a way involving substantial time and effort. Recently, this variable has played a significant role in communication research. Tapper, 20 Shrum and O'Guirm, 21 and Shapiro22 have viewed it as a mediating factor which might help account for mass-media cultivation effects. Also, Pingree has referred to construct accessibility as an element in inference making, a process which can help explain young people's attention to television.23 In the literature, cited determinants of accessibility appear to fall within two basic categories: . Recency and frequency ofuse. Wyer and Srull,24 along with Tversky and Kahneman,25 emphasized recency of use in advancing their "storage-bin" model. These researchers postulate that a construct 128
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used recently goes to the top of the user's storage bin, making it easy to access when another pertinent object requires definition. On the other hand, George Kelly theorized that frequent use of a construct leads one to keep using it, consistently, over a long period.26 Bargh, et al. note that many studies fail to separate frequency and recency. These authors demonstrate that each of these factors can have impact with the other controlled. 27 They, along with Higgins, et al.28 have combined both in attempting to explain construct accessibility. . Motivation or need. Feather 29 suggested that, for example, an object's excitement value may become salient when he or she is bored in a given situation--and/or links liveliness and excitement to basic values of the type stressed by Rokeach. 3° Also, Hawkins, et al. found relatively high attention to a concept or idea when subjects viewed it as difficult to understand, yet probably soluble. sl These studies point to the importance of need in motivating people to use a construct. This focus on motivation is consistent with a good deal of work in various disciplines. Research suggests that, when one has an intense need, he or she places great emphasis on factors which might help meet that need. Once the need is actually or potentially met, however, a person may focus elsewhere. Theoretical bases include the following: 1. Abraham Maslow postulated that those lacking in food, clothing and shelter try hard to gain those things. Furthermore, once that's been accomplished, people work primarily to satisfy such "higher-order" needs as social approval and, ultimately, self-actualization. 32 2. Learning theorists Dewey and Humber note that, often, "The initial impetus to action comes from the innate drives, but once the behavior is set in motion..., there come into being ... socio~enic, secondary, learned or acquired drives, impulses, or needs. "3~ 3. In economics, the concept of diminishing marginal utility posits that, as a need is met, goods and services required to meet it lose value. For example, a hungry person may desire an initial cheeseburger for lunch with great intensity. But a third or fourth burger typically has little appeal. 34 Construct accessibility has been defined operationally in several ways. Included are actual use of the construct, as opposed to others, in making an assessment, 35 response latency or time required in estimation, 36 extremity of high or low values assigned, 37 number of instances or exemplars recalled,38 time Summer 1998
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spent attending to construct use, 39 and choice of behavior presumably based on construct assessment. 443 Research appears to shed little light on types o f construct use relating primarily to frequency and/or recency of use vs. need and motivation. We propose a beginning here based on two fundamental premises.
Premise 1. Simple placement of a construct at or near the top o f one's "storage bin" as a result of recent and/or frequent use may prime use of that construct in defining a relatively new object (in this study, osteopathic medicine). Such placement may not, in and of itself, trigger actual use of the accessed construct in assessing things such as the credibility of that new object. Price, et al., observe that some, but not all, accessed constructs are used in making subsequent evaluations. 41
Premise 2. Needs and motives may play an important role in such triggering. Where an especially salient need is not met, it should enhance use of a construct dearly related to that need (priming the construct as defined by Iyengar and Kinder42). But where the need has been met, other constructs may impact heavily on credibility assessment. Osteopathic Concepts Before deriving specific hypotheses, we pause to consider concepts central to osteopathic medicine. Open-ended interviews of osteopathic physicians and other health-care leaders in 1981-243 and 1991, 44 along with a thorough literature review, revealed seven inter-related concepts which serve as cornerstones of osteopathic philosophy and practice. Five were singled out for study here:
1. Treatment of the whole person. At least three meanings seem relevant. First, different organs and parts of the body are interdependent so that, for example, a liver ailment is apt to affect the heart, and vice versa. Second, mind, body and spirit are inter-related. And third, one's physical well-being hinges in large part on his or her psycho-social and physical environment. For example, an abusive home situation or constant exposure to cigarette smoke harms health. 2. Close, caring doctor-patient relations. These can improve patients' confidence and resolve--important factors in health care. 3. Wellness. Involved here are g o o d exercise, diet, and personal hygiene. A body which stays in good shape can often avoid iUnessmand fight it off when it comes. Much less money and pain are needed to avoid a heart attack than to cure or recover from it once it occurs. 130
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4. Osteopathic manipulative treatment. This set of treatment techniques involves using the hands to apply pressure and movement to the bones, joints, and muscles. 5. Family practice. A majority of D.O.s serve as "primary-care" physicians-family or general practitioners, general internists, and general pediatricians. Many feel general practitioners are needed more than ever to help patients manage their health care as a whole within an increasingly complex system of diagnosis, treatment and finance. Yet only a small fraction of allopathic physicians or M . D . s have opted for primary care in recent years. The survey also differentiated between those who had and had not engaged in three experiences presumed to create or enhance awareness of key concepts. Experiences were having a family physician, having heard of osteopathic manipulative treatment, and having discussed wellness with a physician in the past year. Analyses rested on the assumption that each of the three experiences noted involved at least some awareness of one of the concepts listed above. Those with a family physician seem apt to have some concern about caring doctor-patient relations--something often not available in clinics where a patient sees different physicians from visit to visit. Heating of OMT should insure that it enters one's "storage bin" used for future analysis of health-care practice and concepts. And likewise, discussion of wellness should place it in the bin. The three "experiences" differ greatly as to scope. Hearing of manipulative treatment involves decoding of at least--but perhaps only---one message as needed to gain awareness. The second experience, discussion of wellness, implies two-way, topic-specific doctor-patient interaction. And the third experience, having a family doctor, involves an ongoing relationship. In light of premise 1 above, such experiences should enhance accessibility of manipulative treatment, wellness, and doctor-patient relations in assessing osteopathic medicine--even by people who had little or no direct experience with osteopathy. This suggests: Hla: Those who have a family doctor link osteopathy to caring physicians more closely than do those without a family doctor. Hlb: Those who have heard of OMT link manipulation more closely to osteopathy than do those who have not heard of it. Hlc: Those who have discussed wellness with a physician in the past year link it more closely to osteopathy than do those who report no such discussions. Premise 2 suggests, however, that experiences involving exposure to the three constructs just noted may not influence use of those constructs in assessing osteopathic credibility. To test this, we examine three research questions, indexing such usage with product-moment correlations between closeness of linkage to osteopathy on the one hand and D.O. credibility on the other: Summer 1998
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RQla: Does the correlation between linkage of caring physicians to osteopathy and D.O. credibility differ between those who have a family physician and those who do not? RQlb: Does the correlation between linkage of manipulative treatment to osteopathy and D.O. credibility differ between those who have heard of manipulation and those who have not? RQlc: Does the correlation between linkage of wellness to osteopathy and D.O. credibility differ between those who have discussed wellness with physicians in the past year and those who have not? Hypotheses 2, 3a, 3b, and 3c focus on the extent to which presumed intensity ofpersonal need might "prime" one concept, cost, and make it salient in assessing osteopathy. Cost was chosen here because, in the survey, 78% of all respondents listed it, or a related concern for health-care availability, as "the most important problem facing American health care today." It's widely assumed that costs are an especially grave problem for those without what they regard as good health insurance. People worried about costs should also evaluate D.O. credibility partly on the basis of whether they link osteopathy to cost containment. Thus: H2: The correlation between linkage of osteopathy to cost containment and D.O. credibility is positive for the uninsured but not for those with health insurance. In formulating hypotheses 3a, 3b, and 3c, we focused on three concepts for which linkage to osteopathy correlated positively and significantly with D.O. credibility for the sample taken as a whole. These constructs were wellness, caring physicians, and treatment of the whole person. We presume that respondents very satisfied with their health insurance regard cost-related needs largely as met for themselves. That fact, along with premise 2 above, suggest: H3a: Linkage of wellness to osteopathy correlates positively with D.O. credibility among those very satisfied with their health insurance, but not among the less satisfied. H3b: Linkage of whole-person treatment to osteopathy correlates positively with D.O. credibility among the very satisfied insurance customers, but not among the less satisfied. H3c: Linkage of caring physicians to osteopathy correlates positively with D.O. credibility among the very satisfied insurance customers, but not among the less satisfied. Premises 1 and 2 above provide little reason to believe motivation, in and of itself, enhances construct use in simply defining an object. To provide some cues on this, we explore three research questions: 132
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Needs and Beliefiin ConstructAccessibility RQ2a: Does closeness of linkage between wellness and osteopathy differ between those very satisfied with their health insurance and those who are less satisfied or are uninsured? RQ2b: Does closeness of linkage between whole-person treatment and osteopathy differ between those very satisfied with their health insurance and those who are less satisfied or are uninsured? RQ2c: Does closeness of linkage between caring physicians and osteopathy differ between those very satisfied with their health insurance and those who are less satisfied or are uninsured?
METHODOLOGY
Sampling Data were collected by phone, and random digit dialing was used to select a sample o f Ohioans. Numbers identified by recordings as nonworking were not counted in computing the response rate of about 60%, which was nearly identical for the state's extant area codes. Where no response or recording was encountered, interviewers made three caU-backs at least 24 hours apart before coding a given number as a non-response. In all, 390 interviews were completed. Interviewing Students in journalism and political communication at the researchers' university served as interviewers. Most were graduate students. All underwent intensive training and practice for about two hours before collecting data. The researchers supervised interviewing constantly during data collection, which took about three weeks in late April and early May 1991. Interviews lasted for about 15 minutes.
Measurement Several questions were repeated from a survey completed about nine years earlier by two of the authors to permit analysis of change over time. Such analyses are summarized elsewhere.45 Approximately 20 pre-test interviews were completed, and mid-course corrections in question wording made, prior to actual data collection. Linkage beliefi. Respondents were given the following question: Now I am going to read off a few concepts relating to health care. Please tell me how closely you believe each concept is linked to osteopathic medicine today. Is the connection with osteopathy very close? Fairly close? Or not close at all? Summer1998
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Concepts rated were manipulative treatment, wellness (diet, exercise, and lifestyle measures), treatment of the whole person, lowering of health-care costs, and caring physicians. Linkage ratings were obtained near the end of the questionnaire. Questions about the Linkage constructs had been asked earlier but were interspersed with other items to avoid priming specific linkages. Further, prior questions were worded so as to suggest an association between only one linking construct, manipulation, and osteopathy. These questions came early in the questionnaire. And, it would seem, any priming effect of prior questions should have held about equally across subjects. Having or not having learning experiences. Questions used to measure these three dichotomous variables were as follows: Do you have a family physician to whom you go regularly? Have you ever heard the term "manipulative treatment"? These days, quite a few Americans are trying to stay well through exercise, diet, avoidance of drinking or smoking, and other so-called wellness efforts. Do you recall discussing wellness practices or concerns with a physician during, say, the past year, or not?
D.O. credibility. Respondents indicated their levels of agreement or disagreement with the statement that "Osteopathic physicians are at least as well qualified and trained, on the whole, as medical doctors or M.D.s." Options given were agree strongly, agree somewhat, disagree somewhat, and disagree strongly. Health-insurance posture. Respondents first indicated whether they had health insurance, offered by a private firm, to help pay for hospitalization, drugs, and other health care. Then those with insurance were asked whether they were very satisfied with it, fairly satisfied, or not satisfied at all. Only 10% of those answering said they were not satisfied at all, so the SPSS-PC+ RECODE command was used to combine the "not satisfied at all" and "fairly satisfied" categories in analysis.
Analysis Means were analyzed with multiple classification analyses, using education level as a covariate likely to correlate with active linkage and credibility assessment. MCA provides F ratios as tests of significance and standardized beta weights akin to those in multiple regression, indicating the predictive power of variables measured on a nominal scale. In testing other hypotheses, product-moment correlations were computed between D.O. credibility and the closeness of linkage between osteopathy and specific healS-care concepts. Predictions were directional in every case, so onetail tests of significance were used. Where appropriate, correlation coefficients were converted to the Fisher Z statistic and differences between them were tested for significance. ~ 134
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Inspection of mean scores confirmed that relationships were close to being linear as assumed with product-moment correlation. Interaction tests with analysis of variance confirmed that no two correlations which were compared differed primarily because one defined a linear relationship and the other did not. Uninsured respondents, those who were not fairly or not at all satisfied with their health insurance, and the very satisfied insurees might differ as to education and age--factors which could affect health-care assessment. However, observed differences were slight and did not approach statistical significance.
RESULTS
Sample Description The sample proved quite representative of all Ohioans as demographics, based on the 1990 U. S. Census. Median age was 37.5 years for sample members, compared with 33.3 years for the population as a whole.47 (A difference of roughly this magnitude was expected because no one under age 18 was interviewed.) Women and highly educated people were over-represented somewhat as often occurs in survey research. 48 With respect to the learning experiences noted above, 80% of the respondents reported having regular family doctors. Also, about 31% said they had heard of osteopathic manipulative treatment. Of these, few appeared to have drastic misconceptions about these procedures. Finally, 51% of the respondents reported discussing wellness with a physician during the past year. Moving to linkage beliefs, only 15% of all respondents who assessed doseness of linkage saw a very dose tie between osteopathy and lowering of costs, while 36% said the connection was "not close at all." "Very close" ratings were in the range of 36% to 45% for the other four concepts (OMT, wellness, treatment of the whole person, and caring physicians). And between 47% and 55% saw fairly close ties between osteopathy and each of the five variables. In another area, 14% of all respondents said they did not have health insurance. Of those who were insured, 39% reported being very satisfied with their coverage, while 51% were fairly satisfied and 10% were not satisfied at all. In assessing D.O. credibility, 37% of all respondents indicated they could not assess the validity of the statement that D.O.s are at least as well trained and qualified as M.D.s. Of the remainder, 26% disagreed with the statement, 46% agreed somewhat, and 28% agreed strongly. to
Hypothesis Tests Hypothesis la asserts that those with family physicians link osteopathy more closely to "caring physicians" than do those without family doctors. Table 1 provides confirmation here, though with a fairly weak associaSummer 1998
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tion (b=.17) with education and the other two "learning experiences" controlled. Hypothesis lb specifies that those who have heard of OMT link it to osteopathy more closely than those who report no awareness of manipulation. This difference is moderate (b--.30) and highly significant. Hypothesis lc posits that those who have discussed wellness with physicians in the past year link it more closely with osteopathy than do others. While the difference between means in table 1 is in the predicted direction, it approaches but does not attain significance (p=.088). In sum, those who have family doctors--and those who have learned of OMT--link osteopathy more closely to concepts associated clearly with these experiences than do others. A similar difference involving wellness was in the predicted direction but not significant. While modest, the differences observed seem noteworthy because they appear to hold despite limited contact with osteopathy. Less than 5% of the total sample reported having D.O.s as family physicians. Also, the reported relationships held, with minimal change and without exception, where this group of 19 was excluded from the analysis. Previous research also suggests low awareness by the general public of this school of medical practice. In one study, some people who had been diagnosed or treated at an osteopathic hospital did not realize they had done so, suggesting low general awareness of osteopathy even among some of its customers.49 And research has also shown low media coverage of osteopathy--as well as low awareness of it among those lacking personal contact with D.O.s and osteopathic hospitals, s0 Research questions la, lb, and lc ask whether the correlation between linkage of three concepts to osteopathy and D.O. credibility differs between those who've had learning experiences which might "prime" the concepts and those who have not. In relation to research question la, the correlation between linkage of osteopathy to caring doctors and D.O. credibility was positive (r--.23, p <.01) for those who had family physicians. However, the correlation became non-significant (r= .17) for those who did not have family doctors (see Table 2). Turning to research question lb, the correlation between linkage of manipulation to osteopathy and D.O. credibility was positive for those aware of OMT (r=.18, p <.05), but negative among the "non-hearers" (r=-.20, p <.01). Furthermore, the difference between these two correlations was significant (t=2.56, p <.01, one-tail test). These results suggest an interesting interpretation. Some who'd not heard of OMT apparently said, in effect, "We don't know what it is, but we don't like the sound of it. Therefore, we view osteopathy as a bit suspect to the extent that it deals with manipulation." Of course, the results may stem from negative connotations for the word manipulate. Research question lc focused on the correlation between linkage of wellness to osteopathy and D.O. credibility. Consistent with a priming effect, the 136
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Needs and Beli~ in Comtruct Accessibility TABLE
1
Mean Linkage Scores on Manipulation, Wellness, and Caring Physicians for Those with and without Related Learning Experiences Those with Experience
Those without Experience
p
b+
Reported Awareness
2.51 (n--96)
2.08 (n--120)
.001
.30
Wellness
Discuss with Physician
2.41 ( n = 1 2 8 )
2.29 ( n = 1 0 5 )
.088
.12
Caring Physician
H a v e Family Doctor
2.34 ( n = 1 7 1 )
2.00 ( n = 3 4 )
.005
.17
Concept
Experience
Manipulation
Note: +Standardized beta weights were generated in multiple classificationanalysis, with F-tests used to determine significance levels.Means were adjusted for education levelas a covariatein computing F values and beta weights.
correlation was positive and significant only among those who'd discussed wellness with physicians during the past year (r=.26, p <.01). No significant association was found (r--.15, p >.05) among the non-discussants. Overall, then, those with experiences apt to enhance awareness of key concepts (OMT, caring physicians, and wellness) showed demonstrable positive correlations between closeness of linkage and D.O. credibility. Those who lacked such experiences did not. Conceivably, negative reactions to the word "manipulation" by people unaware of this treatment mode might have influenced responses to the concepts of wellness and caring physicians. To check this, partial correlations were computed for correlations between D.O. credibility on the one hand and wellness or caring physicians on the other, controlling for awareness of manipulation. Partialing changed none of the correlations in Table 2 by more than .01, suggesting little if any such halo effect. A caveat is in order, however. Only with osteopathic manipulative therapy were the correlations between the "experiencers" and the "non-experiencers" significantly different. Furthermore, in the case of caring physicians, the small number of people without family physicians (only 20% of the sample) reduced the power of this statistical test greatly. Thus confirmation that the three learning experiences "primed" related concepts in assessing osteopathic credibility must be viewed as highly tentative. As noted earlier, people with pertinent experiences apparently linked caring physicians, OMT, and wellness to osteopathy--and tended to use it as a basis for assessing D.O. credibility--even though they'd had little or no experience with osteopathic medicine. To further check this interpretation, we calculated the correlations used to test hypothesis 2 while excluding the 19 people (4.8% of the sample) who reported having D.O.s as family physicians from the analysis. No correlation changed significantly. Summer 1998
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TABLE 2 Product-moment Correlations between Linkage to Osteopathy and D.O. Credibility among Those with and without Relevant Learning Experiences Those with Experience
Concept
Experience
Manipulation
Awareness
.18" (n=88)
Wellness
Discuss with Physician
Caring Physician
H a v e Family Doctor
Those without Experience
t
pa
-.20* (n=90)
2.56
.01
.26** (n= 104)
.15 (n = 84)
0.78
nsd
.23** ( n = 139)
.17 (n = 26)
0.29
nsd
Notes: *p < .05, 1-tailtest; **p < .01, 1-tail test. aProbability basedon t-test of differencesbetween correlationsconvertedto Fisher Z statistic.
Hypothesis 2 specifies a positive correlation between linkage of osteopathy to cost containment and D.O. credibility among those without health insurance, but not among the insured. As expected, r=.35 (n= 16, p=.09, onetail) for the uninsured, but only -.07 (nsd) for those who had insurance. The difference between these two correlations approached, but did not attain, significance (t=1.58, p=.06, one-tail). Thus there was only tentative confirmation of hypothesis 2. While substantial, the difference between these correlations was not significant in light of the small number of uninsured respondents. As stated in hypothesis 3a, linkage ofweUness to osteopathy correlated significantly with D.O. credibility among the very satisfied insurance customers (r=.28, p <.05, one-tail), but not among the less satisfied people (r=.12, nsd). However, the difference between these two correlations did not approach significance (t= 1.02, nsd) (see Table 3). AS expected with hypothesis 3b, linkage of whole-person treatment with D.O. credibility correlated significantly among the very satisfied insurance customers (r=.43, p <.01), but not among the less satisfied (r=.10, nsd). Furthermore, the difference between these two correlations was significant (t=2.09, p <.025, one-tail). AS predicted in hypothesis 3c, there was a significant positive correlation between linkage of whole-person treatment and D.O. credibility among the very satisfied insurance customers (r=.39, p <.01), but not among the less satisfied (r=.10, nsd). Furthermore, the difference between these two correlations was significant (t= 1.76, p <.05, one-tail). In sum, then, data on hypothesis 2 suggest tentatively that concern for cost among the uninsured may "prime" that concept as defined by Iyengar and Kinder (1993, pp. 63-72). At least some of the uninsured appeared to rely quite heavily on cost concerns when assessing osteopathy. 138
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Needs and Beliefi in Censtr~t Accessibility TABLE 3
Product-moment Correlations between Linkage to Osteopathy and D.O. Credility among Very Satisfied and Less Satisfied Health-Insurance Customers Concept
Very S a t i ~ d with Health Insurance
Not Very Satirfied or Not Satisfi~d A t All
ta
p
Wellness
.28"* (n--70)
.12 (n--96)
1.02
nsd
Whole-Person Treatment
.43"* (n= 68)
.10 (n= 97)
2.09
.02
Caring Physician
.39** (n=64)
.10 (n=88)
1.76
.05
Notes:
**p < .01, 1-tail. aProbability based on t-test of differences between correlations converted to Fisher Z statistic.
Also the data on hypotheses 3a, 3b, and 3c suggest lack of such priming-with cost receding into the background--among the very satisfied insurance customers. These people, in turn, appear to assess osteopathy partly on the basis of its perceived connection with such health-care "luxuries" as wellness, caring physicians, and whole-person treatment. Research questions 2a, 2b, and 2c asked whether those very satisfied with their health insurance, the less satisfied insurees, and the uninsured differed as to closeness of linkage between wellness, whole-person treatment, and caring physicians, respectively, with osteopathy. Table 4 reveals a negative answer in each case, with no difference approaching statistical significance. Apparently, then, those satisfied with health insurance did not "downplay" cost concerns in a way which led them to link other concepts closely to osteopathic medicine. TABLE 4
Mean Linkage Scores on Wellness, Caring Physicians and Whole-Person Care for Those without Health Insurance and Insured Persons with Varied Levels o f Satisfaction Not Very,
Fairty
Very
Uninsured
Satisfied
Satisfied
F
df
p
Wellness
2.31
2.28
2.40
1.06
2/235
.35
Whole-Person Care
2.41
2.28
2.44
1.71
2/237
.18
Caring Physician
2.22
2.25
2.31
0.27
2/208
.76
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SUMMARY AND CONCLUSIONS Data were collected by telephone from a general-population sample of 390 Ohioans. Respondents rated five concepts as to closeness of linkage with osteopathic medicine. Concepts were treatment of the whole person, dose doctor-patient relations, wellness, osteopathic manipulative treatment, and family medical practice. In general, data supported the following conclusions: 1. Despite limited prior contact with osteopathic medicine, respondents linked the concepts quite closely to this health-care field. In cognitive-theory terms, they pulled concepts out of their "mental storage bins" when defining osteopathy. 2. Those reporting experiences likely to enhance recency and frequency of construct use linked constructs more closely to osteopathy than did people lacking such experience. 3. Those without health insurance--along with those who expressed at least some dissatisfaction with their insurance--had a substantial positive correlation between linkage of cost to osteopathy and osteopathic credibility, though the relationship narrowly failed to reach conventional significance levels in light of a small number of cases. This correlation disappeared among the highly satisfied insurees. The data suggest tentatively that concern with cost went with a fek need which "primed" that factor somewhat in assessing D.O. credibility. 4. In general, those very satisfied with their health insurance showed relatively high correlations between linkage of other selected concepts (doctorpatient relations, whole-person treatment, and wellness) to osteopathy and D.O. credibility. Among these respondents, "de-priming" of cost may have opened the way for assigning weight to other constructs. In sum, recency and frequency of concept use appeared to enhance accessibility so as to encourage linking of constructs with osteopathic medicine. Presumed respondent need did not correlate with closeness of linkage. However, need was associated with the further step of using constructs in evaluating credibility of the associated school of osteopathic medicine. Construct accessibility qualifies as a fruitful area for public relations research. It suggests ways in which educational activity can lay a "cognitive groundwork" for assessment of a new or relatively unknown program, institution, or profession. Further, it supports the potential utility of cooperative public relations and educational activity among disparate, or even competing, professions. Such cooperation seems needed in light of recent calls for enhanced emphasis on mutual understanding and a sense of community. A c k n o w l e d g m e n t : This article is a revised version of a paper originally presented to the Public Relations Division, Association for Education in Journalism and Mass Communication, during the AEJMC annual conference in Kansas City, MO, August 11-14, 1993. 140
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NOTES 1. Leon Festinger, "Behavioral Support for Opinion Change," Public Opinion Quarterly 28 (1964), pp. 404-417. 2. Herbert Blumer, Symbolic Interactionism: Perspectiveand Method (Englewood Cliffs, NJ: Prentice-Hall, 1969), pp. 93-100. 3. James E. Grunig, "Communication Behaviors and Attitudes of Environmental Publics: Two Studies,"Journalism Monographs 81 (1983), pp. 4-9. 4. Min-Sun Kim and John E. Hunter, "Attitude-Behavior Relations: A Meta-Analysis of Attitudinal Relevance and Topic," Journal of Communication 43 (1993), pp. 101142. 5. James E. Grunig, ed. Excellence in Public Relations and Communication Management (Hillsdale, NJ: Lawrence Erlbaum Associates, 1992). 6. Larissa A. Grunig, James E. Grunig, and William P. Ehling, "What is an Effective Organization?" in James E. Grunig (ed.), Excellence in Public Relations and Communication Management (Hillsdale, NJ: Lawrence Erlbaum Associates, 1992), pp. 6590. 7. James E. Grunig, Larissa A. Grunig, and Dejan Vercic, "The Status of Public Relations in Slovenia: Extending the IABC's Excellence Project," paper presented to the Association for the Advancement of Policy, Research, and Development in the Third World, Cancun, Mexico, November 1996. 8. Kathleen S. Kelly, '~Fhe Fund-Raising Behavior of U. S. Charitable Organizations: An Explanatory Study," Journal of Public Relations Research 7 (1995), pp. 111-137. 9. Norman H. Anderson, "Cognitive Algebra: Integration Theory Applied to Social Attribution," in Leonard Berkowitz (ed.), Cognitive Theories in Social Psychology (New York: Academic Press, 1978), pp. 1-101; Martin Fishbein and Icek Ajzen, "Acceptance, Yielding and Impact: Cognitive Processes in Persuasion," in Richard E. Petty, Thomas M. Osttom, and Timothy C. Brock (eds.), Cognitive Responses in Persuasion (Hillsdale, NJ: Lawrence Erlbaum Associates, 1981), pp. 339-359; Milton J. Rosenberg, "A Structural Theory of Attitude Dynamics," Public Opinion Quarterly 14 (1960), pp. 319-340; Joseph Woelfel, Michael J. Cody, James Gillham, and Richard A. Holmes, "Basic Premises of Multidimensional Attitude Change Theory: An Experimental Analysis," Human Communication Research 6 (1980), pp. 153-167. 10. Hugh M. Culbertson, "Linkage Beliefs: What are the Links?" Public Relations Review 18 (1992), pp. 335-347. 11. Hugh M. Culbertson and Hochang Shin, "Police in America: A Study of Changing Institutional Roles as Viewed by Constituents," in James E. Gnanig and Larissa A. Grunig (eds.), Public Relations ResearchAnnual 1 (1989), pp. 155-174. 12. Hugh M. Culbertson and Guido H. Stempel III, "Linkage Beliefs and Public Relations Effects," Public Relations Research and Education 2 (1985), pp. 23-35. 13. Carl J. Denbow and Hugh M. Culbertson, "Linkage Beliefs and Diagnosing an Image," Public Relations Review 11 (1985), pp. 29-37. 14. Hugh M. Culbertson and Guido H. Stempel III, A Study of the Public Relations Posture of Osteopathic Medicine in Ohio (Columbus, OH: Ohio Osteopathic Association, 1982), pp. 46-47. 15. D. Garth Taylor, "Pluralistic Ignorance and the Spiral of Silence: A Formal Analysis," Public Opinion Quarterly 46 (1982), pp. 311-335. Summer1998
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16. Robert N. BeUah, Richard Madsen, William M. Sullivan, Ann Swidler, and Steven M. Tipton, The Good Society (New York: Vintage Books, 1992), pp. 179-219. 17. Parker J. Palmer, The Company of Strangers: Christians and the Renewal of America's Public Life (New York: Crossroad, 1992), pp. 17-33. 18. Dean Kruckeberg and Kenneth Starck, Public Relations and Community: A Reconstructed Theory (New York: Praeger, 1988), pp. 111-119. 19. Everett M. Rogers, Diffusion of Innovations (New York: Free Press, 1995), pp. 240242. 20. John Tapper, "The Ecology of Cultivation: A Conceptual Model for Cultivation Research," Communication Theory 5 (1995), pp. 36-57. 21. L.J. Shrum and Thomas C. O'Guinn, "Processes and Effects in the Construction of Social Reality: Construct Accessibility as an Exploratory Variable," Communication Research 20 (1993), pp. 436--471. 22. Michael A. Shapiro, "Memory and Decision Processes in the Construction of Social Reality," Communication Research 18 (1991), pp. 3-24. 23. Suzanne Pingree, "Children's Cognitive Processes in Constructing Social Reality," ]ournalismQuarterly 60 (1983), pp. 415422. 24. Robert S. Wyer and Thomas K. Snail, "Category Accessibility: Some Theoretical and Empirical Issues Concerning the Processing of Social Stimulus Information," in E. Tory Higgins, C. Peter Herman, and Mark P. Zanna (eds.), Social Cognition: The Ontario Symposium, Vol. 1 (Hillsdale, NJ: Lawrence Erlbaum Associates, 1981), pp. 161-197. 25. Amos Tversky and Daniel Kahneman, "Availability: A Heuristic for Judging Frequency and Probability," Cognitive Psychology 5 (1973), pp. 207-232; Amos Tversky and Daniel Kahneman, "Judgment Under Uncertainty: Heuristics and Biases," Science 85 (1974), pp. 1124-1131. 26. George A. Kelly, The Psychology of Personal Constructs (New York: W. W. Norton, 1955), pp. 72-77. 27. John A. Bargh, Ronald N. Bond, Wendy J. Lombardi, and Mary E. Tota, "The Additive Nature of Chronic and Temporary Sources of Construct Accessibility," Journal of Personality and SocialPsychology 50 (1986), pp. 869-878. 28. E. Tory Higgins, Nicholas A. Kuiper, and James M. Olson, "Social Cognition: A Need to Get Personal," in E. Tory Higgins, C. Peter Herman, and Mark P. Zanna (eds.), Social Cognition: The Ontario Symposium, Vol. 1 (Hillsdale, NJ: Lawrence Erlbaum Associates, 1981), pp. 395420. 29. Norman T. Feather, "Bridging the Gap between Values and Actions," in E. Tory Higgins and Richard M. Sorrentino (eds.), Handbook of Motivation and Cognition: Foundations of Social Behavior, Vol. 2 (New York: Guilford Press, 1990), pp. 151192. 30. Milton Rokeach, BelieJk,Attitudes and Values (San Francisco: Jossey-Bass, 1968). 31. Robert P. Hawkins, Yong-Ho Kim, and Suzanne Pingree, "The Ups and Downs of Attention to Television," Communication Research 18 (1991), pp. 53-76. 32. Abraham H. Maslow, "Psychological Data and Value Theory," in Abraham H. Maslow (ed.), New Knowledge in Human Values (Chicago: Henry Regnery Co., 1959), pp. 123-135. 33. Richard Dewey and Wilbur J. Humber, The Development of Human Behavior (New York: Macmillan, 1951), p. 171. 34. D.W. Moffat, EconomicsDictionary (New York: Elsvier, 1976), p. 178. 35. Tversky and Kahneman, 1973, op. cit.; Tversky and Kahneman, 1974, op. cit. 142
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Needsand Beliefiin ConstructAccessibility 36. 37. 38. 39. 40. 41. 42. 43. 44.
45. 46. 47. 48. 49. 50.
Shnam and O'Guinn, op. cit. Bargh, et al., op. cit. Shapiro, op. cit. Pingree, op. cit. Feather, op. cit. Vincent Price, David Tewksbury, and Elizabeth Powers, "Switching Trains of Thought: The Impact of News Frames on Readers' Cognitive Responses," Communication Research 24 (1997), pp. 481-506. Shanto Iyengar and Donald R. Kinder, News That Matters: Television and American Opinion (Chicago: University of Chicago Press, 1987), pp. 63-72. Culbertson and Stempel, 1982, op. cit. Hugh M. Culbertson, Carl J. Denbow, and Guido H. Stempel III, "David and Goliath Co-Exist: The Story of Osteopathic Public Relations," in Hugh M. Culbertson, Dennis W. Jeffers, Donna B. Stone, and Martin Terrell (eds.), The Social, Political and Economic Contexts in Public Relations: Theory and Cases (Hillsdale, NJ: Lawrence Erlbaum Associates, 1993), pp. 227-269. Ibid. Quinn McNemar, Psychological Statistics (New York: John Wiley and Sons, 1963), p. 140. 1990 Census of Population: General Population Characteristics, Ohio (Washington, DC: U. S. Department of Commerce, 1990), p. 1. 1990 Census of Population and Housing: Summary Social, Economic, and Housing Characteristics, Ohio (Washington, DC: U. S. Department of Commerce, 1990), p. 59; 1990 Census of Population: General Population Characteristics, op. cir., p. 127. Culbertson and Stempel, 1982, op. cit., p. 43. Culbertson, Denbow, and Stempel, 1993, op. cit., pp. 253-255.
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